Children's Ministry Medical Release form for Western Heights Baptist ChurchThis form is valid from January 1, 2019- December 31, 2019.

* Required

Email address *

Your email

Child's first and last name *

Your answer

Male/female *

Male

Female

Child's date of birth *

MM

/

DD

/

YYYY

Child's age/grade *

Birth - age 2

Age 3 - kindergarten

Grade 1-6

Parent/guardian first and last name *

Your answer

Address line 1 *

Your answer

City *

Your answer

State *

Your answer

Zip code *

Your answer

Best phone number *

Your answer

Alternate phone number

Your answer

If parent/guardian is not available in an emergency, notify *

Your answer

Relationship of emergency contact to child *

Your answer

Emergency contact phone number *

Your answer

Additional emergency contact name

Your answer

Relationship of additional emergency contact to child

Your answer

Additional emergency contact phone number

Your answer

Does this child have any of the following allergies? *

Penicillin

Latex

Insect stings

Other drugs

None

Other:

Required

Food allergies? If so, what?

Your answer

Any other allergies? If so, what?

Your answer

Does this child have any medical or health problems/conditions, and or has this child had any chronic or recurring illness or illnesses *

Yes

No

Other:

If yes, please describe the problems or illnesses

Your answer

Child's family physician *

Your answer

Physician's phone number *

Your answer

Describe any dietary restrictions this child is required to follow

Your answer

List any physical restrictions that would limit participation in any activities

Your answer

Date of child's last tetanus shot

Your answer

Is there medical or hospitalization insurance which provides benefits for this child? *

Yes

No

Name of insurance company

Your answer

Phone number

Your answer

Policy holder's full name

Your answer

Policy number

Your answer

Group number

Your answer

In the event that medical care is required during the time period specified above, I (we) hereby grant permission for the appropriate staff member or adult sponsor of Western Heights Baptist Church, Waco, Texas, to secure medical care for my (our) child, and I (we) hereby grant the physician(s) permission to provide any and all medical care necessary (including examination, diagnosis, anesthesia, medical , hospital, and surgical procedures or treatments) for my child's well-being. I (We), the undersigned parent(s) and/or guardian(s) of the above child, do hereby release, acquit, discharge, and hold harmless Western Heights Baptist Church and its representatives, from any and all damages and liabilities arising out of the medical care provided to my (our) child under this Medical Authorization. I (We) understand the Western Heights Baptist Church and its representatives shall incur no liability whatsoever while attending to the medical needs of my (our) child and for obtaining medical care for my (our) child as they deem appropriate. If only one parent or guardian signs this instrument such individual hereby represents that he or she has obtained the other parent's or guardian's agreement to the terms of this instrument.